MII IG Kerndatensatz-Modul Onkologie
2027.0.0-ballot.1 - Germany

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Beispiel Observation: Verlauf - 6 Monate nach modifizierter Therapie


German


status: Final

code: Status of regression of tumor (observable entity)

subject: Martin Beispiel Male, DoB: 1958-11-03

focus: Condition Bösartige Neubildung: Colon ascendens

effective: 2025-03-10

value: Vollremission (complete remission, CR)

note:

Patient completed modified chemotherapy protocol (6 cycles FOLFOX4 + 6 cycles LV5FU2). Despite early discontinuation of oxaliplatin due to neuropathy, patient achieved complete response. CT scan and colonoscopy show no evidence of recurrence. CEA normal (1.8 ng/mL). Peripheral neuropathy has improved to grade 1 but persists. Patient is disease-free at 6-month follow-up.

component

code: Status of residual neoplasm (observable entity)

value: Kein Tumor nachweisbar

component

code: Presence of metastatic neoplasm in regional lymph node (observable entity)

value: kein Lymphknotenbefall nachweisbar

component

code: Status of distant metastasis (observable entity)

value: Keine Fernmetastasen nachweisbar